Taking the History of Medical Ethics Seriously in Teaching Medical Professionalism

Delese Wear and Mark G. Kuczewski (2004) propose that medical educators take a critical step back and rethink the professionalism movement in our medical education. One of their recommendations is that medical educators "should enlist medical students and residents in developing a theory of professionalism." They further recommend that students be encouraged to develop the habit of writing about "activities, learning experiences, and reflections that they believe are important in their professional development."

The implication of these remarks is that our students and residents are free to start their reflections on professionalism from scratch, because no significant reflection to which they are intellectually accountable precedes their own reflections. This implication is underscored by the fact that nowhere in their article do Wear and Kuczewski provide an account of the concept of professionalism and its development in the recent history of medicine.

This implication is unfounded. The physician-ethicists John Gregory (1724-1773) and Thomas Percival (1740-1803), two giants of the history of medical ethics, gave us the concept of medicine as a profession: physicians are the fiduciaries of their patients (McCullough 1998). This concept has three main components (Gregory 1772; Percival 1803).

First, the physician must be competent. He or she must possess a reliable body of knowledge and clinical skills and be committed to their continuous improvement following the intellectual discipline of Baconian scientific medicine. Bacon anticipated what we now call evidence-based medicine, on which Gregory therefore insisted. Percival pioneered the idea of developing hospital registries to gather outcomes data that could then be used to improve patient care. Being competent, Gregory argued, requires that a physician be "open to conviction"; that is, willing to challenge and even change one's most cherished beliefs on the basis of scientific evidence. This capacity is put into practice through the intellectual virtue of diffidence, a disciplined indifference toward one's own beliefs and practices. Evidence-based medicine thus becomes a matter of professional responsibility and accountability.

Second, the physician should use his or her knowledge and skills primarily for the benefit of patients, keeping the pursuit of self-interest in a systematically secondary place. This life of service requires considerable self-sacrifice. Setting justified limits on the virtue of self-sacrifice becomes one of the central ethical issues in medical professionalism. Notice that the issue is not whether being a physician requires self-sacrifice; for Gregory and Percival, and therefore for us, this is not the question.

Third, medicine as a profession is a public trust. Medicine does not belong to physicians alone but is a corporate and social entity that exists primarily for the benefit of patients and science.

Gregory's and Percival's concept of medicine as a profession had enormous influence. Gregory's work was translated into the major continental European languages, and both Gregory and Percival fundamentally shaped the subsequent development of American medical ethics (Baker et al. 1999). Their concept of medicine as a profession is altogether recognizable; it continues to draw our students to the study of medicine.

Given the substantive conceptual achievements of historical figures such as Gregory and Percival, the concept of medicine as a profession does not need development by ourstudents and residents de novo. Our students and residents are therefore not free to choose what they think medical professionalism is. Instead, they need to come to terms with the intellectual discipline that the history of medical ethics imposes on us. To think otherwise is to suppose, mistakenly, that the concept of medicine as a profession isup for grabs, for each student or resident to fashion as heor she sees fit. Recommending that students engage inreflections on professionalism unhinged from the history of medical ethics becomes (unwittingly one hopes) a formula for the de-professionalization of medicine—accomplished, ironically, in the name of improving the discourse of professionalism in medical education.

Most of our students come to...